COVID-19 Wellness Screening Questionnaire
Please be advised in an effort to ensure safety and prevent the spread of COVID-19 we ask that when you arrive for your appointment please check in with the front desk. If we are ready to take you in immediately we will do so, otherwise, we kindly ask that you wait in your car or outside until we call you to go in to your treatment. Please remember to wear a mask when entering the clinic.
Sign in to Google to save your progress. Learn more
First name *
Last name *
Do you have a confirmed case of COVID-19 or have had close contact with a confirmed case of COVID-19? *
Are you required to quarantine by the government?
Clear selection
Checkbox if you have any of the following symptoms: *
Please be assured that our office has always met the regulations set forth by public health.  However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office is taking all measures set by public health given COVID-19.  However, due to the nature of our treatments, a 6 foot distance is not always possible between our clients and service providers.  Re-entering public life comes with some risks that we all must weigh, but we also want you to feel confident that our office is taking every step to keep our customers and staff safe during this difficult time. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided at Body & Soul Clinic *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy